Sentinel Lymph Node Concept; and Sentinel Lymph Node Concept; and Technique of SLN Identification in Breast Technique of SLN Identification in Breast

Cancer PatientsCancer Patients

Dr S.GambhirDr S.GambhirDepartment of Nuclear MedicineDepartment of Nuclear Medicine

S.G.P.G.I.M.SS.G.P.G.I.M.SLucknowLucknow

These PowerPoint presentations are free to download only for These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and academic purposes, with due acknowledgements to authors and

this website.this website.

Axillary Lymph Node Dissection (ALND) in Axillary Lymph Node Dissection (ALND) in Carcinoma BreastCarcinoma Breast

Axillary clearance for local disease controlAxillary clearance for local disease control

PrognosisPrognosis

Early Carcinoma BreastEarly Carcinoma Breast

Histopathological positivity of axilla on ALND 30% ~40%Histopathological positivity of axilla on ALND 30% ~40%

60-70% patients of primary carcinoma breast patients are 60-70% patients of primary carcinoma breast patients are undergoing unnecessary ALNDundergoing unnecessary ALND

ALND associated morbidity ALND associated morbidity

? Adjuvant chemotherapy? Adjuvant chemotherapy

Technical Issues in SLN Detection and Technical Issues in SLN Detection and ImagingImaging

What tracer ?What tracer ?

What injection site ?What injection site ?

Large or small volume.Large or small volume.

How many MBq’s ?How many MBq’s ?

Technical Issues in SLN Detection and Technical Issues in SLN Detection and ImagingImaging

What is most appropriate site of injectionWhat is most appropriate site of injection

SubareolarSubareolar PeritumoralPeritumoral IntratumoralIntratumoral SubdermalSubdermal SubcutaneousSubcutaneous

Concept of Single InjectionConcept of Single Injection

Lymphatic drainage of breast consists of dermal and Lymphatic drainage of breast consists of dermal and parenchymal lymphatics which meet at Subareolar parenchymal lymphatics which meet at Subareolar lymphatics which meet at subareolar plexus of Sappey.lymphatics which meet at subareolar plexus of Sappey.

This further drain through one or two major lymphatic This further drain through one or two major lymphatic trunk to axilla.trunk to axilla.

Position of this lymphatic plexus gives the opportunity of Position of this lymphatic plexus gives the opportunity of single uniformally consistent subareolar injection of single uniformally consistent subareolar injection of injection of radiopharmaceutical/blue dye into breast injection of radiopharmaceutical/blue dye into breast lymphatics.lymphatics.

Adjuvant Systemic therapyAdjuvant Systemic therapy

Radioactive but non blue lymph node

Invitro demonstration of radioactive but non blue lymph node

ResultsResults

Imaging + veImaging + ve 84.8%84.8%

Probe +ve Probe +ve 97.3%97.3%

Blue dye +ve Blue dye +ve 91.4%91.4%

Concordance betweenConcordance between probe and blue dyeprobe and blue dye 94.4%94.4%

SLN histopathology SLN histopathology 97.2 % (accuracy)97.2 % (accuracy) (H.E. matched with axilla nodes)(H.E. matched with axilla nodes)

Technical Issues in SLN Detection and Technical Issues in SLN Detection and ImagingImaging

Which mode of detection is preferable ?Which mode of detection is preferable ?

Probe detection and imagingProbe detection and imaging

Probe detection onlyProbe detection only

Blue dye alone or in combination with probe detectionBlue dye alone or in combination with probe detection

Best Method of SNB Mapping?Best Method of SNB Mapping?

Positive Non-Sentinel Axillary Nodes in Positive Non-Sentinel Axillary Nodes in Patients with Positive Sentinel NodesPatients with Positive Sentinel Nodes

Tumor Size

+NSN

T1a

14%

T1b

22%

T1c

30%

T2

45%

T3

57%

Technical Issues in SLN Detection and Technical Issues in SLN Detection and ImagingImaging

What pathological evidence is required?What pathological evidence is required?

Fine-needle aspiration cytologyFine-needle aspiration cytology

Imprint cytologyImprint cytology

H.E. Staining aloneH.E. Staining alone

Cytokeratin immunohistochemistryCytokeratin immunohistochemistry

ConclusionConclusion

Currently detection of SLN is highly accurate in Currently detection of SLN is highly accurate in context of carcinoma breast.context of carcinoma breast.

There is rapidly increasing database population.There is rapidly increasing database population.

Training programmers relevant to Training programmers relevant to multidisciplinary teams need to be developed for multidisciplinary teams need to be developed for this methodology.this methodology.